儿童癫痫指南
Clinical monitoring for adverse effects likeweight loss, eye symptoms like blurring, redness,watering and eye pain (glaucoma/myopia),metabolic acidosis(73) and oligohydrosis(74) isnecessary in all cases. Decreased appetite and weightloss are expected and should be communicated to thecaregivers. Cognitive adverse effects can beminimized by converting to topiramatemonotherapy, if possible.
Hydration should be maintained and calciumsupplements should be avoided to minimize risk ofrenal stones.Levatiracetam
It should be used only as an add-on drug to refractorypartial(75,76) and some generalized epilepsies like,refractory absence or progressive myoclonicepilepsies(77). It is not recommended to be used as afirst-line agent in newly diagnosed epilepsies,though recent data support a role in the idiopathicgeneralized epilepsies of adolescents (JME etc).Behavioral adverse effects like aggression are themost common adverse effects, rarely a paradoxicalincrease in seizure frequency may occur and thisshould be monitored carefully.
The usual effective dose is between 20-60 mg kg /day. One can start at 20 mg/kg in two doses andincrease every 1-2 weeks till 60 mg/kg/day.Tiagabine
As add-on in refractory partial seizures(78). It is notrecommended as monotherapy in children withnewly diagnosed epilepsy. NCSE (non convulsivestatus epilepticus) can occur in about 8% of patientsand should be carefully excluded in children whoseseizures/mental status deteriorate on treatment(79).It is used in an initial daily dose 0.1 mg/kg TID;increased weekly by 0.1 mg/kg; maximum daily dose0.4 and 0.7 mg/kg (uninduced and induced,respectively). In children over 12 years, it can beinitiated at 4 mg/day; total daily dose increased by 4mg in week 2 (divided doses); then increased by 4 to8 mg/day (divided doses) each week until clinicalresponse is achieved or to a maximum daily dose of32 mg/d is reached.12. Ketogenic Diet in Epilepsy
The ketogenic diet (KD) is a stringently controlledhigh fat and low protein/carbohydrate diet givenwith/without a restricted fluid intake to maintainketosis on a long term basis(80). It has been shownthat it is more efficacious than newer AEDs incontrolling refractory seizures(81) and is more costeffective. It can be used with both non-vegetarianand vegetarian diets at any age and for all types ofseizures. It has significant improvements inhyperactivity and aggression in almost allpatients(80,81). Hence, it should be tried in allchildren above the age of 1 year with drug-resistantepilepsy, especially those who are not a surgicalcandidates or where surgery cannot be performeddue to availability/affordability issues. Referral tocenters providing the KD should be considered onceadequate trials of three AEDs have failed, suggestiveof pharmacoresistant epilepsy(82). Adverseeffects(83) include GI disturbances, acidosis,increased susceptibility to infections, drowsiness,weight loss, nutritional deficiencies and rarely, renalcalculi and pancreatitis. Most of these occur early inthe diet and should be carefully monitored. The dietshould be considered a failure if there is no benefit in3-6 months and it should be discontinued after thistime. In responders, it should be continued for 2-3year after which it is gradually tapered.13. Surgically Remediable Syndromes
All infants and children with refractory partial orgeneralized epilepsy should be referred as early aspossible to a comprehensive epilepsy center forpossible surgical evaluation. This process should beexpedited if there is an imaging documentedunilateral lesion or if the epilepsy is havingsignificant effects on the child’s development.Ideal surgically remediable syndromes(84)include:
Hemispheric epilepsies with pre-existingcontralateral hemiplegias/visual field defectscaused by large unilateral gliotic lesions/atrophy,Rasmussen’s encephalitis, hemispheric dys-plasias etc, where hemispherectomy/hemis-pherotomies could offer a possible surgicalcure.